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Can My Insurance Company Selectively Review Certain Medical Records While Ignoring Others In Considering My LTD Benefits?

Attorney Rachel AltersAuthor: Attorney Rachel Alters

It is common practice by insurance companies to “cherry pick” medical records during the LTD review process, taking the claimant’s physician’s notes out of context in an attempt to validate the denial or termination of benefits. Often times, insurance companies will find one or two notes from a claimant’s physician that state he or she has improved or is feeling better and base the denial on those notes alone while ignoring all other pertinent medical records. There could be hundreds of pages of records and lab tests documenting disabling medical issues, but the insurance company will focus solely on those one or two sentences, usually taking them out of context, in order to deny or terminate a claimant’s benefits.

Unum unfairly terminates benefits after paying claimant for over ten years

This exact scenario occurred in the case of Hannon v. Unum Life Ins. Co, U.S. District. LEXIS 181381 (S.D.Ind November 26, 2013). In this case, the court granted summary judgment in favor of the Plaintiff, against Unum, who worked as a registered nurse but suffered from a connective tissue disorder called Ehler-Danlos syndrome. Hannon was paid LTD benefits by Unum for over 10 years, but after Unum performed a paper review of her records, it was determined that she was capable of performing full-time sedentary work. Hannon’s treating physicians all held the opinion that she was incapable of performing more than 4 hours of sedentary work a day due to her disabling condition. In her summary judgment motion, Hannon argued that Unum “cherry picked statements from her treating physician that supported the termination of benefits, while completely ignoring the entirety of her claim file comprised of over 2000 pages.” The court held that Unum took her doctor’s statement out of context and that Unum’s “selective review does not provide sufficient justification to terminate the LTD benefits that Unum paid continuously for ten years.” Interestingly, the court also found that Unum abused its discretion by basing the denial on her ability to perform household chores. The Seventh Circuit firmly stated that “casual equating of household work to work in the labor market cannot stand.” Gentle v. Barnhart, 430 F.3d 865, 867 (7th Cir. 2005).

It is important to note that the Court’s decision in Hannon suggests that when an insurance company pays benefits for a significant period of time (i.e. 10 years) it should make sure that when terminating benefits, the claimant’s condition has truly improved significantly and that this improvement is supported by convincing medical documentation. The court in the case at hand was highly suspicious of Unum’s motive for terminating benefits when its decision was based on a few pages of medical records taken completely out of context.

It is imperative that you communicate all of your issues to your treating physicians and make sure they are documenting your medical restrictions and limitations accurately. Too many times a claimant will state that they were unaware that their doctor was not documenting their complaints of pain or difficulties functioning. Without such documentation, your claim will likely be denied. This is why it is important to have legal counsel monitoring your claim even after your benefits have been approved, as there is no guarantee that your insurance company will continue to pay your benefits until you are 65.

There are 2 opinions so far. Add your comment below.

Bradley:

Dear Sir,

I am just starting a LTD claim process with Cigna. That being said, can you please help understand the best process for the for submitting all pertinent medical records from multiple physiciansto Cigna. The Cigna claim clerk made an initial call and asked me to fax all of my records to their central facsimile station. However, I have a great amount of records and am concerned that parts of my fax will get missed or lost from altogether. Finally, I am a master at getting my medical records from my doctors and in fact, have records from spine surgeries going back to 2004 to present. In the initial claim process, is it appropriate to send Cigna as all medical records that I have available or should I be more selective in topic and date?

Claiming LTD for: Multiple (x5) Lumbar spinal surgeries, CTD akin to Sjogren’s or Lupus and now an exacerbation w/ new cervical and thoracic spine decease.

Thank you very much for providing so much help.

Attorney Stephen Jessup:

Bradley,

Please feel free to contact our office to discuss your pending application and how we may be able to assist you in securing your benefits.

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